Severe pulmonary hypertension and circulatory failure associated with Congenital syphilis. Case report

BACKGROUND

Congenital syphilis is a vertical infection caused by Treponema pallidum. Despite the implementation of preventive strategies during pregnancy, its incidence is increasing, and it constitutes an important public health problem. Most patients with congenital syphilis are asymptomatic; however, a small group may develop severe disease at birth with the need of advanced resuscitation in the delivery room, acute hypoxemic respiratory failure, and hemodynamic instability. Therefore, awareness is needed.

METHODS AND RESULTS

This series describes the clinical course of two late preterm infants with congenital syphilis who developed acute hypoxemic respiratory failure, pulmonary hypertension, and circulatory collapse early after birth. Integrated hemodynamic evaluation with neonatologist-performed echocardiography (NPE) and therapeutic management is provided.

CONCLUSIONS

A comprehensive hemodynamic evaluation including early and serial functional echocardiography in these patients is needed to address the underlying complex pathophysiology and to help to establish accurate treatment.

Congenital syphilis unusually presenting with prematurity-related severe neonatal morbidities including meconium obstruction: A case report and review of the literature

RATIONALE

Congenital syphilis (CS) can manifest as a variety of clinical presentations according to the severity in symptomatic infants during neonatal period. Preterm neonates with CS may have more clinical evidences of infection and be more severely affected by CS compared with term ones. With increasing survival of markedly premature infants for recent decades, CS may be a challenging problem in those with severe manifestations associated with combined pathophysiologies of CS and prematurity.

PATIENT CONCERNS

A very low birth weight infant at 32 weeks gestation presented with an unusual CS presentation consisting of prematurity-associated severe neonatal morbidities including meconium obstruction, prolonged cholestatic jaundice with elevated liver enzymes, and disseminated intravascular coagulation with a bleeding diathesis, in addition to common or typical manifestations of CS.

DIAGNOSES

Congenital syphilis.

INTERVENTIONS

Therapy consisting of a complete course of parenteral penicillin, blood component therapy, proximal ileotomy with inspissated meconium evacuation and distal loop ileostomy, and other conservative treatments.

OUTCOMES

Resolution with normal gastrointestinal function and improved liver function was observed.

LESSONS

This case suggests that in premature infants CS may manifest as unusual severe neonatal morbidities that may result from combination of syphilitic pathologies and contributors or conditions associated with prematurity including multisystem immaturity.

[Clinical features of 121 infants below 3 months of age with congenital syphilis]

OBJECTIVE

To investigate the clinical features and diagnosis of infants under 3 months of age with congenital syphilis.

METHOD

Data of 121 infants below 3 months of age with congenital syphilis were collected from January 1997 to May 2007 at the authors' hospital. Their clinical features, laboratory findings and treatment were reviewed.

RESULT

Clinical manifestations of congenital syphilis in the infants were diverse. The disease involved multiple systems such as the skin, respiratory, digestive, blood, and nervous system, skeleton and so on. Among the 121 infants, the manifestations included increased leukocyte count (89.3%), skin damage (59.5%), hepatomegaly (56.2%), splenomegaly (41.3%), anemia (38.8%), fever (28.9%), pathologic jaundice (24.0%), growth retardation after birth (12.4%) and bone damage (54.3%), etc. The rate of misdiagnosis was 17.4 percent, and the kinds of disease misdiagnosed were up to 10.

CONCLUSION

Clinical manifestations of congenital syphilis in infants under 3 months of age were complicated and nonspecific, therefore doctors misdiagnosed it very easily. Clinicians should attach great importance to it. At the same time, the restoration of antemarital examination, vigorously carrying out screening for syphilis and strengthening the management of immigrants are necessary to prevent congenital syphilis.

Influence of mother VDRL titers on the outcome of newborns with congenital syphilis

Congenital syphilis still represents a significant public health problem worldwide, and particularly in developing countries. Despite years of research on different clinical and immunological features, many physiopathological aspects still lacks of knowledge, one of them the role of immune response against Treponema pallidum by infected mothers on the birth outcomes, e.g. birthweight. In this study we analyzed if the mother VDRL titers were significantly associated with the birthweight of newborns with congenital syphilis. We observed a highly significant association between both variables, finding at the linear regression that with higher mother VDRL titers, the newborn birthweight was lower (p=0.0345). We identified that higher VDRL titers are associated with lower birth weights, although the physiopathological reasons to explain this still remains unclear.

Intrauterine infections

Editor’s Note: This information is excerpted from the chapter, “Intrauterine Infections,” in the new book: Infection in the Neonate: A Comprehensive Guide to Assessment, Management, and Nursing Care. Ordering information can be found on the facing page, or you may order online at: www.neonatalnetwork.com/nicuink.

Maternal syphilis: pathophysiology and treatment

Despite the long history of medical interest in syphilis and its effects on pregnancy outcome, many fundamental questions about the pathophysiology and treatment of syphilis during pregnancy remain unanswered. However, understanding has been advanced by recent scientific reports such as those which delineate the complete sequence of the genome of the syphilis spirochaete, provide a more precise description of fetal and neonate infection by use of rabbit infectivity tests and describe the gestational age distribution of fetal death secondary to syphilis. It appears that fetal syphilitic involvement progresses in a rather predictable fashion, and although there is disagreement about the optimal prenatal treatment regimen, programmatic efforts to prevent fetal death must provide seropositive pregnant women with a recommended treatment early in pregnancy, and certainly before the third trimester.

Case report of an SGA infant with jaundice, direct hyperbilirubinemia, hepatosplenomegaly, thrombocytopenia, and a negative VDRL

This case report highlights the presentation of syphilis in a small-for-gestational age (SGA) female infant who was born to a mother with no prenatal care. In the first 2 days of life, the infant developed hepatosplenomegaly, conjugated hyperbilirubinemia, thrombocytopenia, and hemolysis. After extensive diagnostic investigation, the case was solved on the infant's day of life (DOL) 12. In retrospect, the health care team had obtained a diagnostic result that could potentially have solved the case on DOL 2. Although this infant suffered no long-term sequelae secondary to the delayed diagnosis, the review of this case presentation may assist other clinicians in an early identification of a potentially lethal diagnosis.

Congenital syphilis in Harris County, Texas, USA, 1990-92: incidence, causes and risk factors

From local health department data, we determined the 1990-92 incidence of congenital syphilis (CS) in Harris County, Texas, USA, applying for the first time the Centers for Disease Control and Prevention (CDC) 1990 surveillance case definition to a population-based sample. We also evaluated factors that discriminated between women whose infants were or were not cases. The incidence of CS per 1000 live births was 3.2 in 1990, 4.6 in 1991 and 4.2 in 1992. Because of failure to apply part of the case definition, the local health department reported only 60% (418/694) of the cases that we identified. In the multivariate analysis, the significant factors for CS were lack of prenatal care and late latent syphilis. No factor identified high-risk women to target for special public health interventions. Improved laboratory services and better education of local providers and surveillance workers will solve some problems in the diagnosis and therapy of syphilis during pregnancy. Ambiguity in the CDC's case definition of CS needs correction.

Congenital syphilis

Congenital syphilis offers many parallels with perinatal HIV infection. Both affect multiple organs including the central nervous system, may be asymptomatic for months to years, and pose diagnostic dilemmas, especially from a laboratory perspective. Syphilis is a co-infection in some cases of HIV. Public policy issues raised by the AIDS epidemic, including stigmatization, discrimination, and denial of access to health care, have their antecedents in syphilis.

Absence of lower extremity ossification centers in term infants with congenital syphilis

Radiologic evaluation is valuable for confirmation of congenital syphilis. Bony abnormalities are thought to be secondary to active disease or a growth response of bone to systemic illness. Anteroposterior lower extremity radiographs of 85 euthyroid term infants (> or = 38 weeks' gestation; mean weight, 3244 gm; range, 1940-4380 gm) with presumptive congenital syphilis were evaluated for the presence of the distal femoral and proximal tibial secondary ossification centers and other bony abnormalities. Both proximal tibial and distal femoral ossification centers were absent in only 9 of 85 infants with syphilis; the proximal tibial center was absent in 26 of 85 (total 30.6%; 95% confidence limits 0.2 to 0.4). This observation is significant at the p < 0.01 level by chi-square analysis with use of historical controls. Periosteal new bone formation was seen in 2 of 85 infants. Metaphyseal lucent bands were present in 21 of 85 infants, 8 of whom also had absent lower extremity ossification centers. For comparison we reviewed lower extremity radiographs from 12 term infants without congenital syphilis. Ossification centers were absent in one growth-retarded infant, and metaphyseal lucent bands were found in one infant. Although standard texts report nearly universal ossification of the distal femoral epiphysis at term, we observed delayed skeletal maturation in 30.1% of term infants with congenital syphilis. We speculate that this delay may be reflective of systemic infection.

Liver function in early congenital syphilis: does penicillin cause a deterioration?

In this prospective study, neonates with clinical congenital syphilis were investigated to determine if penicillin therapy caused a deterioration in liver function. The relationship between circulating immune complexes and liver involvement was monitored, and the efficacy of steroid therapy as an adjunct in the treatment of congenital syphilis was investigated. Thirty neonates with clinical congenital syphilis were randomly assigned into two groups: one group received penicillin therapy only, and the other group penicillin and prednisone as an adjunct. Twenty-one infants who did not have clinical or serological syphilis, born to seropositive mothers, served as a "control" group. Liver function tests, full blood counts, and immunological studies were performed at various intervals up to 3 months of age. Although the symptomatic groups differed significantly from the asymptomatic group in most of the parameters measured, there were no significant differences noted between the two symptomatic groups at any time point. No direct relationship between penicillin therapy and either deteriorating liver function or the presence of circulating immune complexes could be demonstrated. Also, prednisone therapy did not modify any of the parameters studied.

Auditory brain-stem responses in syphilis

Analysis of auditory brain-stem electrical responses (BSER) provides an effective means of detecting lesions in the auditory pathways. In the present study the wave patterns were analysed in 11 patients with secondary or latent syphilis with no clinical symptoms referrable to the central nervous system and in two patients with congenital syphilis and general paralysis. Decreased amplitudes and prolonged latencies occurred frequently in patients with secondary and with advanced syphilis. This technique is a notable diagnostic advance in detecting syphilitic damage of the brain stem.